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Advice on dosette boxes highlights lack of evidence

By News team

The Royal Electronicjuice has issued its first professional guidance on multi-compartment compliance aids (MCAs), saying there is insufficient evidence to support the benefits of MCAs in improving medicines adherence in patients or improving patient outcomes.

The RPS recommends the use of original packs to supply medicines to patients in the absence of a specific need requiring an MCA as an adherence intervention.

Martin Astbury, President of the RPS, said: “Although MCAs may be of value to help some patients with problems managing their medicines and maintaining independent healthy living, they are not the only intervention for all patients and many alternative interventions are available. Pharmacists need to be empowered to work with patients to find the best intervention that helps people use their medicines.”

Lack of clear, consistent and reliable advice

The guidance was necessary because of a lack of clear, consistent and reliable advice on the use of MCAs and their place in supporting patients taking their medicine, added Alex McKinnon, the RPS director for Scotland.

Alternatives to MCAs, noted in the guidance, include patient counselling and health coaching, reminder charts, medicines administration record charts, large print labels, information sheets, and telemedicine and IT solutions, such as smartphone apps.

The 29-page guidance says pharmacists cannot fully implement the recommendations on their own and that an integrated approach between health and social care, between commissioners and service providers, and among pharmacy bodies is required to improve patient outcomes. There had been a fact-sheet on MCAs, written by the RPS when it was the regulator, but it was more regulatory in tone. The new “Improving patient outcomes: the better use of multi-compartment compliance aids” guidance is designed to be more patient focused.

The RPS and the Pharmaceutical Services Negotiating Committee are planning a roundtable to work out how the recommendations can be implemented.

The guidance was sent to a wide range of individuals and organisations for comment, including the British Medical Association. No patient organisations were consulted on the guidance, although an “expert patient” provided input, a spokeswoman for the RPS told PJ Online.

GPs welcome guidance

Bill Beeby, chairman of the prescribing committee of the BMA general practitioners committee, welcomed the guidance. He told PJ Online that the BMA and the PSNC would be writing jointly to local medical and pharmaceutical committees to encourage the use of the document and for it to into discussions with patients, carers and the NHS.

He added: “It is a useful document and it helps deal with the issues relating to MCAs as well as dealing with the misconceptions around them. For example, the key misconception is that an MCA improves compliance.”
Alastair Buxton, head of NHS services for the PSNC, said: “Commissioners, all health professionals and other providers will need to collaborate on this.” 

Mixed response from care homes

However, there has been a mixed response from organisations representing care providers.  Frank Ursell, chief executive officer of the Registered Nursing Home Association, which represents owners of small- to medium-sized nursing homes, told PJ Online: “Rather than this being a balanced report looking at the evidence on both sides, the conclusion seems to rely purely upon the perceived lack of evidence to prove the value of MCAs. 

“While one understands, and accepts, that services should be patient centred, unfortunately in regulated services such as care homes, a regulator is quick to label a care home as ‘unsafe’ if they find any errors in the administration of medication. MCAs have a part to play in helping to ensure that a safe environment is maintained for patients.”

Des Kelly, executive director of the National Care Forum, a membership body for not-for-profit care homes, told PJ Online that the RPS guidance appeared to support the findings of its multidisciplinary work on medicines safety in care homes earlier this year.

He said: “The National Care Forum supports the person-centred/patient-centred approach being advocated and underpinned by communication between all the professionals involved in the person’s care. MCAs should not be utilised automatically.  In our view, regular medication reviews led by pharmacists are the best way to ensure a safer, better quality of service to care homes and their residents. Care homes reported to us mixed benefits of using MDS (monitored dosage systems).”

Citation: Electronicjuice DOI: 10.1211/PJ.2013.11123773

Readers' comments (5)

  • The response from Frank Ursell indicates a failure to recognise the difference between a dosette box type pack designed to be used by an individual and blister packed medication provided to support staff administration of medication in care homes.  The latter is for the benefit of staff and management, with the outcome of potentially fewer medication errors so the patient does benefit.  The former is often instigated without proper assessment of how the patient is best assisted.


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  • MCAs are often used inappropriately in care homes as a substitute for good staff training. There is little evidence that they improve patient care and safety in care homes - look at the CHUMs study. There is little or no evidence that they improve safety in care homes.

    We need to move away from the use of MCAs as default in the care home environment. We should start from the premise that all patients can self-medicate, unless they have been assessed as needing support. An MCA should only be used for a patient who has been assessed as needing one - irrespective of where they happen to be resident (care home or otherwise).

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  • We are continually approached - often quite aggresively - by Intermediate Care, care service providers & family members to supply MCAs. This will provide us with something that we can use to fend of these often unnecessary requests. A properly supported training pack on carrying out an assessment is urgently needed to go hand in hand with this. Well done the authors!

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  • Agree Steve, a training resource and nationally agreed tools to ensure a consistent approach. 

    We also need a united front from the profession. MCAs can and are still used to achieve market share of prescriptions. 


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  • the Pharmaceutical Industry spends an enormous amount of money is presentation and packaging to ensure the stability of their medication. The industry has the responsibility for this. Once tablets and capsules are removed and repackaged into these boxes where does the the legal responsibility lie in ensuring that the patient gets the full correct dose of the medication that has been prescribed and not a percentage dose in a deteriorating tablet? This has serious implications for both the patient and also the drug manufacturer if the drug does not work. It is also totally misleading for the prescriber who may stop using a perfectly good medication because of poor results.

    Could some legal experts give their opinions on the legal implications of this?

    Will the manufacturers of these containers accept the liability of ensuring and guaranteeing the stability of medication presented in these containers?

    Some manufacturers state on their packaging that medication should be kept in original packaging until used. Why don't all manufacturers do this?


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